What can be done vs. what should be done

Tanveeruddin, a 75 year old man is in Intensive care of a tertiary care hospital in Karachi since the last ten days. He was admitted because of worsening dyspnea for the last two months and was ventilated within an hour of arrival due to severe uncorrectable hypoxia. He was diagnosed as carcinoma of lung six months ago and was declared inoperable due to extensive disease with metastases in bone and brain. At home he was on pain killers and more recently on N/G feeding due to cachexia. He was completely bed bound since the last two weeks and confused. Tanveeruddin has been a smoker since his youth, and ran a grocery shop near his home. He lived in his own flat with his wife and two unmarried daughters. He had been supported during this illness financially by his brother, as most of his saving was already consumed in diagnosis of his original pathology, including CT scan chest and abdomen, bronchoscopy, MRI brain, isotope bone scan and laboratory tests. In the hospital he had multiple medical issues including severe bronchospasm, hyponatremia, uremia, respiratory failure and sepsis. He was treated with Intravenous antibiotics, nebulizers, inotropes, heparin, and other supportive treatment apart from ventilation. To manage him for all this, he had to undergo several tests including CBC, UCE, ABGs, CXR, cultures of body fluids and blood, clotting profile etc. Quite understandably, his relatives were not only worried about his life but also inundated with the medical expenses for which they were borrowing from all available resources, and even sold their jewellery, to save his life. They had asked the treating doctors many times about his condition, and the usual answer was ‘we are doing our best’. As can be expected, despite all this, the patient died after ten days on the ventilator. His wife and daughters are near to selling their house to pay back the loans, apart from worrying about their financial future. What is going on? Were the doctors inefficient? Did they not intelligently diagnose Tanveruddin’s illness and extent initially? Moreover did they not ‘fight’ to save his life in his hospitalization? There were medical conditions that were treatable; there was no neglect during his care; proper councelling was done too. The million dollar question is: whether Tanveeruddin should at all have been put on the medical heroics, including ventilator, knowing that he has a terminal illness and poor quality of life? Had he even recovered after treating the treatable issues, how long more would he have survived? Who should have taken this decision and when? Do our medical books, our medical college curriculum, our CMEs train and sensitize us in these? All what we are educated in, and educate our juniors is, what can be done in such and such case; how is sepsis treated; how is respiratory failure and hyponatremia dealt with, and so on. With advancements in modern medicine and availability of fancy gadgets, most of the previously mysteries are now diagnosable. By the time we are finished declaring that the mass in this 70 year old chronic smoker is a large cell carcinoma, inoperable and metastisized almost everywhere, many patients have spent their meagre savings. Many a time treatment in hospitals is done by junior doctors with consultants only ‘keeping an eye’. The result is wrong decisions on life saving issues, unnecessary tests and treatments, and so on. Needless to say, on many occasions, it’s the greed of the hospitals or doctors to earn more that governs such decisions. Even if it is done in complete honesty, the rationale on how much to do, for how long, is not taken into consideration. ‘Going by the book’ is not always needed; what should be done in the given patient is the best decision. Discomfort of tests, pain, difficulties in travelling, financial burden and several related issues are hardly ever considered important. What to say of the common man: they trust doctors either due to the concept of messiah or simply because of their own ignorance. When the casualty medical officer said to Tanveeruddin’s relatives: ‘he is critical and if we don’t put him on the ventilator soon, he may die’, imagine what choices they had in such a stressful situation? They were ignorant of the prognosis of his lung disease; despite seeing him in very bad shape recently, they were hopeful that he will improve. So they did best for their beloved one. My mother once said: “How have things changed; previously people used to die comfortably among their beloved ones, at home. Now they die painfully in hospitals” One of my teachers Dr Abdul Majeed Memon dealt with such situations with God-gifted qualities. I remember when panicked relatives of a terminally ill 90 year old patient of COPD asked him what to do next, whether to put him on life saving machines or do further tests, he gently yet firmly said: “sit by his side and recite sura-e-Yaseen”